A 67-year-old man is brought by his wife for evaluation of memory loss. Over the last 2 years he has had difficulty recalling the names of friends. On two occasions he has become lost in his own neighborhood. Recently, he has become suspicious that his wife is trying to put him in a nursing home.He has hypertension. He has never used alcohol. He does not have urinary incontinence. His only medication is hydrochlorothiazide 25 mg daily. His mother was diagnosed with Alzheimer disease at age 60.
Blood pressure is 130/76. There are no focal neurologic findings and gait is normal. He is not oriented to date and cannot recall any of three objects at 3 minutes. He cannot speak the name of common objects such as a pen or watch. His clock drawing test is abnormal. Complete blood count, blood chemistries, liver function tests, serologic test for syphilis, thyroid stimulating hormone, and vitamin B12 levels are all normal. CT scan of the brain reveals age-related atrophic changes but is otherwise normal.
Of the following choices, which is the next best step?
A. Begin treatment with donepezil 5 mg dailyThis patient meets the diagnostic criteria for Alzheimer disease: the gradual development of multiple cognitive defects (which must include memory impairment) resulting in significant social impairment, not explained by another physical or psychiatric disease. The primary treatment is a cholinesterase inhibitor. Many clinicians initiate therapy with donepezil. Neurocognitive testing may confirm the diagnosis but is not necessary. The APOE gene on chromosome 19 influences the risk for late-onset Alzheimer disease, but it is not a clinically useful test for influencing diagnosis or treatment. In prospective trials, ginkgo biloba has been demonstrated to be ineffective in the treatment of Alzheimer dementia. Antipsychotics do not affect the course of Alzheimer disease and are reserved for severe behavioral disturbances, which have not responded to nonpharmacological therapy.